Paediatric Asthma

1. Paediatric Asthma Dr Rossa Brugha Clinical Research Fellow 11th February 2014 April 2010

2. Paediatric asthma • What is asthma in childhood? • Pathology, signs and symptoms • Diagnosis • Principles of asthma management • Self management • Pharmacotherapy • Assessing control • What’s new

3. % of 12 yr. olds Burr et al Thorax 2006;61:296-9 The scale of the problem

4. The scale of the problem Changes in the Prevalence of Diagnosed Asthma and Asthma Symptoms over Time in Children and Young Adults. Eder W et al. N Engl J Med 2006;355:2226-2235.

5. Asthma vs preschool wheeze Asthma Preschool wheeze Age 1-5 Approx 1 in 3 children ‘Episodic viral’ wheeze Wheeze only with viral infections No evidence for ICS ‘Multi-trigger’ wheeze URTIs plus other triggers eg exercise, smoke, allergens Only give oral prednisolone in subgroup of those requiring admission • Above age 5 • Approx 1 in 11 children • Inflammatory condition • Responds to inhaled corticosteroids See: Bush A, Grigg J, Saglani S. Managing wheeze in preschool children. BMJ 2014; 348

6. There is no agreed definition, no known cause • Genetic susceptibility plus environmental trigger: • 1st degree relative increases risk • Identical environments in siblings with and without asthma • Time course/“double hit” of atopic sensitization and viral infection eg hRV3; 1st year of life is crucial What is Asthma? Aclinical diagnosis

7. Clinical features that increase the probability of asthma More than one of the following symptoms: • Wheeze, cough, DIB, chest tightness, particularly if symptoms: • are frequent and recurrent • are worse at night and in the early morning • occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold, damp air, or with emotions/laughter

8. Clinical features that increase the probability of asthma • Personal history of atopic disorder • Family history of atopic disorder and/or asthma • Widespread wheeze heard on auscultation • History of improvement in symptoms or lung function in response to adequate therapy

9. Clinical features that lower the probability of asthma • Symptoms with colds only, with no interval symptoms • Isolated cough in the absence of wheeze or difficulty breathing • History of moist cough • Prominent dizziness, light-headedness, peripheral tingling

10. Clinical features that lower the probability of asthma • Repeatedly normal physical examination of chest when symptomatic • Normal peak expiratory flow (PEF) or spirometry when symptomatic • No response to a trial of asthma therapy • Clinical features pointing to alternative diagnosis

11. Airway pathology in asthma The hallmark of asthma is chronic airway inflammation From: Bradding, P., Walls, A.F. & Holgate, S.T. (2006). The role of the mast cell in the pathophysiology of asthma. J Allergy Clin Immunol 117, 1277–84

12. Airway pathology in asthma

14. Signs and symptoms The result of airway inflammation is airway narrowing

16. Self management • Avoid triggers • Air pollution • Passive (active) smoking • Aeroallergens when/if possible • Healthy diet • Studies in adults and children have shown that a high intake of fresh fruit and vegetables is associated with fewer asthma symptoms and better lung function

18. Self management • Exercise • Warm up and warm down • Use bronchodilator pre-exercise • Good evidence that exercise helps asthma • Complementary treatments • Buteyko breathing (a technique to control hyperventilation) has been shown to reduce symptoms

19. Pharmacotherapy Montelukast Steroids Monoclonal anti-IgE (omalizumab, Xolair) Lebrikizumab: anti IL-13 Mepolizumab: anti IL-5 Pascolizumab: anti IL-4

20. Management of chronic asthma

22. During the past 4 weeks: How often did your asthma prevent you from getting as much done at work, school or home? How often have you had shortness of breath? How often did your asthma (wheezing, coughing, chest tightness, shortness of breath) wake you up? How often have you used your reliever inhaler? How would you rate your asthma control ? Asthma control test

23. Comorbidities • Around 50% with asthma will have atopy • Eczema • Rhinitis • Hayfever • Antigen crossing via these sites can persistently sensitise the immune system • Important to optimise epithelial health • Barriers (emollient) • Immunomodulators (topical steroid) • Symptom control (antihistamines)

24. What’s in the pipeline • Phenotyping asthma • Via SNPs eg leukotrienes and ALOX-5 • “Urine dip” for asthma • By sputum leucocytes • By exhaled breath cytokine pattern (Th1, Th2, Th17) • Predicting exacerbations/inflammometry • FeNO (probably not in children) • Sputum eosinophil count (probably not in children) • ACT score • Peak flow fractals

25. Why phenotype? • All that wheezes is not asthma • Consider the approach to management of other chronic inflammatory conditions in childhood • Joint arthropathies • Inflammatory bowel disease

27. Asthma Review: Checklist • The right diagnosis • Check symptom control (ACT) • Ask about and address smoking (child and parent) • The right treatment at the right time (step-wise) • Before initiating a new drug/step: check compliance with existing therapies, inhaler technique and try to eliminate trigger factors. • Minimise side effects from treatment (i.e. growth if on high dose ICS) • The right inhaler, correct technique • Give inhaler training, ensure correct technique before writing prescription

28. The gold standard is MDI + spacer Give Asthma education (repetition, reinforcement, signpost/give resources) All children should have an Asthma Plan Promote self-management Compliance Need regular review Annual review Review at 48-72 hrs and 30 days post exacerbation/admission Asthma Review: Checklist

29. NICE Quality standards QS25 • Statement 1. People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance. • Statement 2. Adults with new onset asthma are assessed for occupational causes. • Statement 3. People with asthma receive a written personalised action plan. • Statement 4. People with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment. • Statement 5. People with asthma receive a structured review at least annually. • Statement 6. People with asthma who present with respiratory symptoms receive an assessment of their asthma control.

30. NICE Quality Standards QS25 • Statement 7. People with asthma who present with an exacerbation of their symptoms receive an objective measurement of severity at the time of presentation. • Statement 8. People aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation. • Statement 9. People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge. • Statement 10. People who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2 working days of treatment. • Statement 11. People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service.

31. Useful learning resources • Acute breathing difficulties:http://abd.ocbmedia.com/home/ • Spotting the Sick child;https://www.spottingthesickchild.com/ • Adult & Paed case studies:http://real.educationforhealth.org/ • Itchy Sneezy Wheezy:http://www.itchysneezywheezy.co.uk/ • Asthma UKhttp://www.asthma.org.uk/

32. Further reading • BTS Guidelines 2011/12 http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx • Atopic Eczema in Children (NICE)http://www.nice.org.uk/CG57 • BNF for Children 2011/12

33. Questions April 2010

34. Summary • Asthma is very common • Large disease burden • Morbidity & mortality • Regular asthma review • Assess control • Assess technique • Assess understanding, compliance/concordance • Question the diagnosis